Impounding Agreement - Virginia State Corporation Commission

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S.A. 13 (7/99)
STATE CORPORATION COMMISSION
DIVISION OF SECURITIES AND RETAIL FRANCHISING
IMPOUNDING AGREEMENT
As a condition of the registration by qualification of the securities described hereafter:
The undersigned issuer agrees that the proceeds from the sale of such securities shall be
delivered in escrow to ________________________________________________ as depository until at
least __________________________________________________ of such securities have been sold and
paid for.
The undersigned depository accepts the duties hereby imposed on it and agrees to hold said
proceeds in trust until authorized in writing by the Division of Securities and Retail Franchising of the State
Corporation Commission to disburse them.
If less than _______ of said securities have been sold within __________months of the date of
this agreement, the proceeds in escrow are to be returned to the subscribers who have paid for the
securities.
The undersigned broker-dealers and agents of the issuer agree to remit immediately to the
depository all proceeds without deduction of any fees, commissions or expenses.
In Witness Whereof, this agreement has been executed as of the _______ day of
_____________, ____, by the issuer, by the depository, by each broker-dealer offering the securities and
by each agent of the issuer offering the securities.
ISSUER
__________________________________
__________________________________
Name of Issuer (Type or Print)
President, Other Appropriate Officer or
General Partner and Title (Type or Print)
__________________________________________________________________________________
Signature of President, Other Appropriate Officer or General Partner
DEPOSITORY
__________________________________
__________________________________
Name of Virginia Depository
Bank Officer (Type or Print) and Title
__________________________________
__________________________________
Address of Virginia Depository
Signature of Bank Officer
(Type or Print)
BROKER/AGENT
__________________________________
__________________________________
Virginia Broker-Dealer (Type or Print)
President or Other Appropriate Officer and
Title (Type or Print)
__________________________________________________________________________________
Signature of President or Other Appropriate Officer
__________________________________
__________________________________
Virginia Broker-Dealer (Type or Print)
President or Other Appropriate Officer and
Title (Type or Print)
__________________________________________________________________________________
Signature of President or Other Appropriate Officer
__________________________________
__________________________________
Agent of the Issuer (Type or Print)
Signature of Agent of the Issuer

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